Buckingham At Norwood, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Norwood, New Jersey.
- Location
- 100 Mcclellan Street, Norwood, New Jersey 07648
- CMS Provider Number
- 315290
- Inspections on file
- 16
- Latest survey
- November 7, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Buckingham At Norwood, The during CMS and state inspections, most recent first.
A non-certified Nursing Aide was assigned independent resident care duties without completing required training and competency evaluations. Despite being hired as a Hospitality Aide, the aide provided direct care, including bathing and feeding, without proper oversight or documentation of training completion. Interviews revealed a lack of oversight and documentation regarding the aide's training and competency.
The facility failed to have the Infection Preventionist (IP) present for three consecutive quarterly QAPI meetings, potentially affecting all 156 residents. The LNHA could not confirm when the Regional Infection Preventionist Nurse (RIPN) began as the IP. The DON provided attendance sheets showing the IP's absence, confirmed by the RIPN. The LNHA admitted non-compliance with the requirement for the IP to be dedicated solely to the IPCP, and the QAPI Plan lacked information on the committee's composition.
The facility failed to complete reference checks for five out of eight newly hired staff members, including RNs and CNAs, before their start date. The HRRD confirmed the oversight, despite the facility's policy requiring reference checks as part of the new hire process.
The facility failed to follow physician orders for medication administration, resulting in multiple medication errors. Residents received medications despite vital signs being outside prescribed parameters, and medications were left at the bedside for a resident's representative to administer, contrary to policy.
A facility failed to properly store and label medications, as observed in a resident's room and across multiple medication carts and storage rooms. Unordered medications were found in a resident's room, and medication carts contained undated and unidentified medications. Additionally, discrepancies in refrigerator temperature logs were noted. The facility's policy lacked guidelines for dating opened medications and handling loose or unlabeled medications.
A facility failed to provide timely breakfast service and maintain privacy during a medical consultation. One resident waited for their breakfast tray while others were served, and an eye doctor attempted to conduct an examination in a dining area, prompting intervention by the RN/UM. These actions violated the facility's policies on meal service and resident rights.
The facility failed to submit MDS assessments within the required timeframe for three residents, as identified during a survey. The assessments, crucial for managing resident care, were completed late for residents with severe cognitive impairments and other health conditions. The MDS Coordinator acknowledged the delay in completing these assessments.
The facility failed to accurately document the vaccination status of two residents in the MDS, leading to discrepancies between the MDS records and the residents' consent forms. The MDS inaccurately indicated that vaccines were not offered, while consent forms showed that the residents' representatives had refused the vaccines. This deficiency was confirmed through interviews with facility staff.
A facility's IDT failed to involve a resident in their care planning and discharge process, leading to a deficiency. The resident, who was independent with activities of daily living, expressed a desire to be discharged but was not invited to care plan meetings. The facility's documentation did not reflect the resident's participation in care planning or any follow-up actions for discharge, despite the resident's expressed wishes.
A facility failed to conduct routine weekly skin checks for a resident, leading to a delay in identifying ulcers on the resident's right foot. The resident, who had multiple medical conditions and required assistance with daily activities, was found with wounds that had serosanguineous drainage. The lack of documentation and failure to perform routine skin checks contributed to the delay in identifying the resident's wounds, which were eventually treated after the resident was sent to the hospital for further evaluation.
Two residents receiving respiratory care experienced deficiencies in equipment storage and infection control. One resident's nebulizer mask was improperly stored, while another resident's contact precaution status was outdated, leading to improper PPE use by staff. Facility policies on nebulizer therapy and transmission-based precautions were not followed.
The facility failed to provide sufficient nursing staff and timely incontinence care, as observed during a survey. Staffing levels were inadequate, with one CNA responsible for a high number of residents, particularly on weekends. Two residents were found with soaking wet diapers, indicating a failure to adhere to the facility's incontinence policy. Despite being informed, the facility management did not refute the findings.
The facility failed to post accurate daily Nursing Home Resident Care Staffing Reports, with discrepancies noted in CNA numbers and census figures. The Unit Clerk, covering for the Staffing Coordinator, used previous day's data to estimate current staffing, leading to inaccuracies. Management was informed but did not refute the findings.
A resident with Alzheimer's Disease did not receive their prescribed Seroquel 12.5 mg at the scheduled time due to the medication's unavailability in the med cart. The LPN acknowledged the issue and contacted the pharmacy for an urgent delivery. The medication was eventually administered later in the day. The deficiency was reported to the facility's administration.
A resident with chronic kidney disease was prescribed Vancomycin for suspected C-diff infection, but lab tests were negative. Despite this, the antibiotic was continued without documented justification, violating the facility's Antibiotic Stewardship Program Policy. Late entries in the medical record were made after surveyor inquiry, indicating a lack of proper documentation and reassessment.
Failure to Ensure Nursing Aide Competency Before Independent Assignments
Penalty
Summary
The facility failed to ensure that a non-certified Nursing Aide (NA #1) received the required training and competencies before being assigned independent resident care duties. NA #1 was hired as a Hospitality Aide and began independent resident care assignments shortly after, without completing the necessary training and competency evaluations. This oversight was identified for one of nine NAs reviewed, who provided direct care to residents across all five nursing units. NA #1 was hired on June 17, 2024, and began independent assignments on July 3, 2024, before being enrolled in a state-approved Nurse Aide Training and Competency Evaluation Program (NATCEP) on July 15, 2024. Despite being enrolled, NA #1 worked 69 shifts without evidence of completing the required skills and competencies. The facility's job descriptions for Hospitality Aides and Nursing Assistants clearly outlined the responsibilities and limitations, yet NA #1 was assigned tasks beyond their training, such as bathing, toileting, and feeding residents. Interviews with facility staff revealed a lack of oversight and documentation regarding NA #1's training and competency. The Director of Nursing and Human Resources staff were unable to provide evidence of NA #1's completed training or competency evaluations. Additionally, NA #1's school confirmed that they did not complete the program, further highlighting the facility's failure to ensure that all NAs were adequately trained before providing direct care to residents.
Removal Plan
- NA #1 was removed from employee schedule
- Staff education on hiring Hospitality Aides and the process for hiring and scheduling Nursing Aides
- DON reviewed all current NA onboarding requirements
- DON reviewed all NAs to confirm they had the required competency skills
Infection Preventionist Absence in QAPI Meetings
Penalty
Summary
The facility failed to have the Infection Preventionist (IP) present for three consecutive quarterly Quality Assurance Performance Improvement (QAPI) meetings, which had the potential to affect all 156 residents currently living in the facility. During an entrance conference, the Licensed Nursing Home Administrator (LNHA) was unable to confirm when the Regional Infection Preventionist Nurse (RIPN) began serving as the facility's IP. The Director of Nursing (DON) provided QAPI attendance sheets for the last three quarters, which showed that the IP did not attend the meetings on 5/29/24, 7/23/24, and 10/22/24. The RIPN confirmed the absence of an IP in these meetings. The LNHA acknowledged that the facility did not comply with the requirement for the designated IP to be dedicated solely to the Infection Prevention Control Program (IPCP). The QAPI Plan provided by the LNHA lacked information on the composition of the QAPI Committee. During a QAPI interview, the LNHA stated that the DON reported on infection control in the absence of the IP. The facility did not provide additional information or refute the findings during the exit conference.
Incomplete Reference Checks for New Hires
Penalty
Summary
The facility failed to ensure that reference checks were completed for five out of eight newly hired staff members before their employment start date. This deficiency was identified during a review of eight randomly selected new employee files, where it was found that several staff members, including Registered Nurses and Certified Nursing Assistants, had incomplete or missing reference checks. Specifically, two RNs had only one reference check each, while three CNAs had no reference checks in their files. The Human Resources Regional Director (HRRD) acknowledged that the facility's process involved asking staff to provide additional references if initial contacts were unreachable, and personal references were required if there was no work history. However, the HRRD confirmed that reference background checks were not completed for the five newly hired staff. The facility's policy on the new hire process emphasized the importance of completing reference checks, but this step was not adhered to, leading to the deficiency.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to physician orders regarding medication administration for several residents, leading to multiple instances of medication errors. For Resident #28, the facility did not follow the physician's order to hold hydralazine when the blood pressure was below 140, resulting in the medication being administered on several occasions despite the blood pressure being below the specified threshold. Similarly, Resident #131 received Humalog insulin even when their blood sugar levels were below the prescribed parameter of 110, indicating a failure to follow the physician's orders. Resident #117, who had severe cognitive impairment, was administered Midodrine despite having a systolic blood pressure greater than 140, contrary to the physician's order to hold the medication under such conditions. This pattern of not adhering to medication parameters was also observed with Resident #140, who received Midodrine when their systolic blood pressure was above the prescribed limit of 120. Additionally, Resident #142 was given Amlodipine and Losartan despite their blood pressure and heart rate being outside the parameters set by the physician. Furthermore, Resident #144 was found with a cup of medications left at the bedside, which were intended to be administered by the resident's representative. This practice was not in line with the facility's medication administration policy, which requires medications to be administered by licensed nurses or authorized staff. The facility's failure to ensure medications were administered according to physician orders and professional standards of practice was evident across multiple instances and residents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store medications for one resident and ensure that medications were stored and labeled appropriately for two medication carts and two medication storage rooms across four nursing units. This was observed when a surveyor found three containers of medications, including L-Lysine, Vitamin D3, and Vitamin B12, in a resident's room without proper storage or orders in the electronic Medication Administration Record (eMAR). The Licensed Practical Nurse (LPN) was unaware of these medications being at the bedside and confirmed there were no orders for them, acknowledging that medications should not be left or stored in the resident's room. Further deficiencies were noted during inspections of medication carts and storage rooms. On one unit, a foil package of Budesonide nebulizer solution was found without a documented date of opening, and loose unidentified tablets were discovered in the medication cart. Similarly, on another unit, a box of Ipratropium/Albuterol nebulizer solution was found with an open foil packet lacking a documented opening date, along with a loose unidentified tablet. The med nurse was unable to identify the tablets and confirmed the absence of opening dates on the foil packages. The surveyor also noted discrepancies in the temperature logs of medication refrigerators, with one refrigerator showing a temperature of 30 degrees Fahrenheit, while the log recorded 40 degrees Fahrenheit. The facility's Medication Storage Policy, revised in October 2023, was reviewed and found to lack specific guidelines regarding the dating of opened medications and the handling of loose, unlabeled, or unidentifiable medications. The Consultant Pharmacist confirmed that opened foil packs should be dated and that the normal refrigerator temperature should be between 36 to 46 degrees Fahrenheit. The surveyor discussed these concerns with facility management, who acknowledged the need for proper medication storage and labeling.
Deficiencies in Meal Service and Privacy During Medical Consultation
Penalty
Summary
The facility failed to provide a dignified dining experience for residents in the 2 South dining area by not serving breakfast in a timely manner. On the morning of 10/31/24, a surveyor observed that one resident, identified as Resident #25, was seated without a breakfast tray while other residents had already received theirs. The breakfast tray for Resident #25 was on a food truck, but the Certified Nursing Aide (CNA) was occupied feeding another resident. The Quality Assurance Corporate Aide (QACA) eventually served the tray after the surveyor's inquiry, indicating a delay in service. Additionally, four residents had to wait 30 minutes for their breakfast trays, which were only served after the arrival of the second food truck. In a separate incident in the 1 South dining area, a lack of privacy was observed during a medical consultation. An eye doctor attempted to conduct an eye examination on Resident #67 in the dining room immediately after the resident finished their meal. The Registered Nurse/Unit Manager (RN/UM) intervened, instructing the doctor to conduct the consultation in the resident's room, as it was inappropriate to perform such procedures in a communal dining area. The facility's policies on serving meals and respecting resident rights were reviewed, revealing that meals should be served promptly and residents have the right to privacy and dignity. The surveyor's findings highlighted deficiencies in adhering to these policies, as evidenced by the delayed meal service and the lack of privacy during a medical consultation.
Late Submission of MDS Assessments for Three Residents
Penalty
Summary
The facility failed to electronically transmit the Minimum Data Set (MDS) assessments within the required timeframe for three residents. The MDS is a critical assessment tool used to manage the care of residents, and according to the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual, it must be completed no later than 13 days after a resident's entry date. However, the assessments for three residents were completed late, exceeding the 13-day requirement. This deficiency was identified during a surveyor's review of the residents' records and interviews with facility staff. Resident #125 was admitted with a diagnosis of encephalopathy and had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment. The comprehensive MDS (cMDS) for this resident was completed more than 13 days after admission. Similarly, Resident #132, admitted with unspecified dementia and other mental health issues, had a cMDS completed late, with a BIMS score showing severely impaired cognition. Resident #212, diagnosed with rhabdomyolysis, also had a cMDS completed beyond the required timeframe, with a BIMS score indicating moderate cognitive impairment. The MDS Coordinator/Registered Nurse acknowledged the delay in completing these assessments during an interview with the surveyor.
Inaccurate MDS Documentation for Resident Vaccination Status
Penalty
Summary
The facility failed to accurately reflect the status of two residents in the Minimum Data Set (MDS), which is a critical assessment tool used for managing care in compliance with federal guidelines. For Resident #125, the MDS inaccurately documented the resident's vaccination status. The comprehensive MDS indicated that the resident had not received the influenza and pneumococcal vaccines, citing reasons such as 'not offered' and 'not eligible-medical contraindication.' However, a review of the resident's consent forms showed that the resident's representative had explicitly refused consent for these vaccinations. This discrepancy highlights a failure in accurately recording the resident's vaccination status in the MDS. Similarly, for Resident #212, the MDS inaccurately reflected that the pneumococcal vaccine was not received because it was 'not offered,' despite the resident's representative having refused consent for the vaccine. The surveyor's interview with the Regional Infection Preventionist Nurse and the MDS Coordinator/Registered Nurse confirmed the incorrect MDS coding. The facility's failure to accurately document the vaccination status in the MDS assessments for these residents constitutes a deficiency in maintaining accurate and compliant resident records.
Failure to Involve Resident in Care Planning and Discharge Process
Penalty
Summary
The facility's interdisciplinary team (IDT) failed to ensure that the care plan for a resident was revised to maintain the resident's highest practicable physical, mental, and psychosocial well-being. The deficiency was identified during a survey when a resident expressed concerns about their discharge plans. The resident, who had been in the facility for several months for rehabilitation therapy, was independent with activities of daily living and did not have a place to stay outside the facility. Despite expressing a desire to be discharged, the resident was not involved in the care planning process, and there was no documentation of the resident being invited to care plan meetings. The resident's medical records revealed that they had a history of atherosclerotic heart disease, hypertension, schizophrenia, and type 2 diabetes mellitus. A quarterly MDS assessment indicated that the resident was cognitively intact. However, the facility's documentation did not show that the resident was invited to participate in care plan meetings or that their wishes regarding discharge were considered. The social worker (SW) responsible for the resident's care planning did not document any follow-up actions or referrals for the resident's discharge planning, despite the resident's expressed desire to leave the facility. The facility's policies on discharge planning and comprehensive care plans require that residents be involved in their care planning and that any decisions regarding discharge be documented. However, the facility failed to adhere to these policies, as evidenced by the lack of documentation of the resident's participation in care planning and the absence of referrals for discharge. The facility's failure to involve the resident in their care planning and to document the discharge planning process led to the identified deficiency.
Failure to Conduct Routine Skin Checks Leads to Delayed Wound Identification
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and facility policies. This deficiency was identified during a review of a facility-reported event involving a resident who was found with ulcers on the right foot. The investigation revealed that weekly skin checks had not been completed for two weeks prior to the identification of the wounds, which were noted with serosanguineous drainage. The resident was subsequently examined by a nurse practitioner, who ordered x-rays, intravenous antibiotics, and various consults before the resident was sent to the hospital emergency room for further evaluation. The resident, who had a history of quadriplegia, major depressive disorder, contractures, peripheral vascular disease, neuromuscular dysfunction of the bladder, and hypertension, was cognitively intact and required assistance with activities of daily living. The facility's records indicated that there was only one documented skin evaluation for the month of August, despite a physician's order for weekly skin assessments. The lack of documentation and failure to perform routine skin checks contributed to the delay in identifying the resident's wounds. Interviews with facility staff, including the LPN who cared for the resident, revealed that the resident was generally cooperative with care but occasionally refused it. The LPN relied on CNAs to notify them of any skin impairments during daily care, but the weekly skin assessments were not consistently documented. The Director of Nursing and the Licensed Nursing Home Administrator, who were not part of the administration at the time of the incident, were unable to provide additional information regarding the investigation conducted by the previous administration.
Deficiencies in Respiratory Care and Infection Control
Penalty
Summary
The facility failed to ensure proper storage and handling of respiratory equipment for two residents receiving respiratory care. One resident, who was cognitively intact and admitted for rehabilitation, had a nebulizer mask that was not stored in a plastic bag as required by facility policy. The nebulizer mask was observed on top of a nightstand, which was confirmed by the resident and a Licensed Practical Nurse (LPN) as improper storage. The resident's medical records indicated a history of asthma, heart failure, and hypertension, and the resident received respiratory therapy for 225 minutes over a seven-day period. Another resident, who had a tracheostomy and was on contact precautions for MRSA, was observed with a nebulizer mask not stored properly. The resident's room had a contact precaution sign, but a Recreation Aide (RA) entered without wearing personal protective equipment (PPE) and did not perform hand hygiene upon exiting. The LPN later clarified that the resident's contact precaution status was outdated, and the sign should have been for Enhanced Barrier Precautions (EBP) instead. The resident's medical records showed a history of intracerebral hemorrhage, chronic respiratory failure, and tracheostomy status, with respiratory therapy provided for 375 minutes over a seven-day period. The facility's policies on nebulizer therapy and transmission-based precautions were not followed, leading to improper storage of respiratory equipment and failure to adhere to infection control measures. The facility's Infection Preventionist Nurse confirmed the deficiencies and acknowledged that the nebulizer masks should have been stored in bags when not in use. Additionally, the RA's failure to follow posted signs for contact precautions was noted, although it was later clarified that the resident was not actively infected with MRSA.
Inadequate Staffing and Incontinence Care Deficiency
Penalty
Summary
The facility failed to ensure sufficient nursing staff and timely incontinence care for residents, as observed during a survey. On multiple occasions, the staffing levels were inadequate, with one CNA responsible for a high number of residents, particularly during weekend shifts. For instance, on a specific day, the Penthouse unit had only one CNA for 18 residents, and similar staffing issues were noted across other units. This staffing shortage was confirmed by interviews with staff and review of the Nursing Home Resident Care Staffing Report (NHRCSR), which showed high staff-to-resident ratios, especially during night shifts. The deficiency was further evidenced by the condition of two residents during an incontinence care tour. Resident #67 was found with a strong smell of urine emanating from their room, and upon inspection, was discovered to be wearing double diapers, which were soaking wet, along with the incontinence pads and bed sheets. The CNA attending to Resident #67 confirmed being the only CNA on duty for the shift. Similarly, Resident #214 was found with a soaking wet diaper, and the CNA responsible for their care also reported being the sole CNA for the unit, managing 37 residents. Interviews with the nursing staff revealed that the issue of insufficient staffing, particularly on night shifts and weekends, was a recurring problem. The facility's incontinence policy, which mandates appropriate treatment and services for incontinent residents, was not adhered to, as evidenced by the condition of the residents. Despite being informed of these issues, the facility management did not provide additional information or refute the findings during the exit conference.
Inaccurate Staffing Reports in LTC Facility
Penalty
Summary
The facility failed to post an accurate Nursing Home Resident Care Staffing Report (NHRCSR) daily for three out of seven days, which could affect the knowledge of staff availability for resident care. On multiple occasions, discrepancies were noted between the posted staffing reports and the actual staffing levels. For instance, on one day, the posted report indicated 13 CNAs for the day shift, while the actual schedule showed only 11 CNAs. Additionally, the census numbers on the posted reports did not match the actual census numbers provided by the Registered Nurse Supervisor. The inaccuracies in the staffing reports were attributed to the process used by the Unit Clerk, who was temporarily covering for the full-time Staffing Coordinator. The Unit Clerk was using the previous day's staffing information to estimate the current day's staffing levels, leading to discrepancies. Furthermore, the Unit Clerk incorrectly counted two noncertified nursing aides (NAs) as equivalent to one CNA, which contributed to the inaccurate staffing numbers. The facility's management, including the Licensed Nursing Home Administrator and the Director of Nursing, were informed of these discrepancies. The Regional Clinical Operation acknowledged that the posted NHRCSR should be accurate and not estimated. Despite being aware of the issues, the facility did not provide additional information or refute the findings during the exit conference with the survey team.
Medication Unavailability Leads to Delayed Administration
Penalty
Summary
The facility failed to administer medication to a resident due to the unavailability of the prescribed drug. During a medication administration observation, an LPN was unable to provide Seroquel 12.5 mg to a resident diagnosed with Alzheimer's Disease, as the medication was not available in the medication cart. The LPN acknowledged the absence of the medication and informed the surveyor that she would contact the pharmacy for an urgent delivery. The resident's medical record indicated a severely impaired cognitive status with a BIMS score of 07 out of 15. The electronic Medication Administration Record (eMAR) showed that the Seroquel was not administered at the scheduled time but was given later in the day once it became available. The last delivery of the medication was recorded on 10/24/24, indicating a lapse in ensuring the medication was restocked in a timely manner. The deficiency was reported to the Director of Nursing, the Licensed Nursing Home Administrator, and the Regional Director of Operations.
Failure to Discontinue Unnecessary Antibiotic
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. The resident, who was admitted with chronic kidney disease and a urinary tract infection, was prescribed Vancomycin for suspected Clostridium difficile (C-diff) infection. However, a lab test conducted after the initiation of Vancomycin treatment returned negative for C-diff toxins. Despite this, the antibiotic treatment was continued without documented justification for its necessity, as required by the facility's Antibiotic Stewardship Program Policy. The surveyor's investigation revealed that the physician's progress notes justifying the continued use of Vancomycin were entered as late entries after the surveyor's inquiry. The Regional Infection Preventionist Nurse confirmed that there was no documented reason for continuing the antibiotic in the resident's medical record or the facility's antibiotic stewardship documentation. The facility's policy mandates reassessment of empiric antibiotics after 2-3 days, but this was not adhered to, leading to the administration of an unnecessary medication.
Latest citations in New Jersey
A resident with severe cognitive impairment, multiple comorbidities, and a stage 4 sacral pressure ulcer required staff assistance with ADLs and had a care plan specifying turning, repositioning, offloading, limited sitting time, and use of a ROHO cushion. While Documentation Survey Reports showed recorded interventions such as skin observation and turning/repositioning from January through March, the facility could not produce any ADL or POC documentation for turning, repositioning, or getting the resident out of bed for the preceding several months. CNAs, an LPN, and the DON reported that these interventions were performed and documented in the POC or progress notes, but the requested records for that time period were unavailable, contrary to facility policies on turning/repositioning and pressure injury prevention that require such care to be implemented and documented.
The facility failed to maintain sufficient kitchen staffing, resulting in days when no cook was on duty and the Food Service Director had to cover all meals. On one such day, residents reported receiving only cold items for all three meals, including cereal and milk for breakfast, cold cut sandwiches and chips for lunch, and cold cut ham wraps for dinner, with no cooked foods or vegetables provided. A Dietary Aide confirmed that both the scheduled cook and the FSD were ill that day, and the RD instructed use of only non-cook items, later acknowledging the meals did not meet daily nutritional requirements. Review of the monthly schedule showed only one cook on staff, with the FSD covering most cooking duties and no backup cooks despite the facility’s policy requiring nutritionally adequate meals even when a scheduled cook is absent.
A resident with dementia, psychotic disorder, seizures, and moderate cognitive impairment was hospitalized for anemia and AKI, where imaging revealed an acute displaced left femur fracture with associated hemorrhage, along with clinical findings of left leg swelling, redness, and tenderness. After being notified by a hospital RN of the fracture, facility leadership conducted an internal investigation, concluded there was no harm done in the facility, and remained unsure where or how the fracture occurred. The LNHA acknowledged that the cause of the injury was unknown, and the CEO confirmed that such an injury of unknown origin should be reported to the Department of Health. Despite a written abuse policy requiring immediate notification to the state and written follow-up within 72 hours when investigating possible abuse or neglect, the facility did not report this injury of unknown origin to the New Jersey Department of Health.
A resident with schizoaffective disorder, major depression, and a documented history of elopement risk had a Wander Guard in place and a care plan calling for frequent monitoring due to active exit-seeking. After the resident’s behaviors escalated, one-to-one monitoring was started but then discontinued when the resident was moved to a secured unit, where policy required controlled exit access. On an evening in question, staff on the secured unit allowed residents to leave unaccompanied to a soda machine on another unit, and the resident was last seen in their room around 9 p.m. By about an hour later, staff discovered the resident missing, and a nurse on another floor, not the secured unit staff, activated a Code Grey after hearing a door alarm. A subsequent head count confirmed the resident had left the building; the resident later stated they exited through a unit door, took an elevator to the front entrance, and used public transportation to visit a family member, demonstrating a failure to maintain a safe secured environment and adequate supervision to prevent elopement.
A resident with severe intellectual disabilities, obstructive and reflux uropathy, and an indwelling catheter was seen by a urologist, who recommended cystoscopy, laser lithotripsy of a bladder stone, and TURP, with a future OR schedule. Nursing documentation noted the recommendation, but there was no evidence in the EMR that staff followed up with the urologist or the physician to schedule the procedures. Central supply staff, responsible for scheduling, reported making weekly calls and tracking them on paper that was not retained and had no EMR access, and leadership confirmed there was no policy for scheduling out-of-facility appointments and no completed follow-up form because the urology office was expected to schedule surgery. The resident was later sent out with cloudy urine, poor intake, and lethargy and was admitted to the hospital with an obstructed Foley, bilateral hydronephrosis, and acute kidney injury, and the lack of documented follow-up conflicted with the facility’s charting policy requiring the medical record to support interdisciplinary communication.
Surveyors found that multiple residents did not receive meals and beverages as listed on their tray tickets, including missing biscuits, condiments, and diet sodas, as well as incorrect items such as apple products despite a documented "no apple" order and food preferences like "no gravy" not being honored. Residents with conditions such as protein-calorie malnutrition, DM, CKD, and other chronic diagnoses had care plans directing staff to provide diets as ordered and honor food and beverage preferences, yet trays frequently did not match tray cards. Kitchen staff acknowledged running out of certain items, and leadership confirmed that trays and tray tickets were expected to match and that meals should follow documented preferences.
A resident with multiple medical conditions and moderate cognitive impairment required substantial assistance with toileting and was care planned for incontinence management and skin integrity. Facility records showed that required documentation of bladder continence, bowel continence, bowel movements, and toilet use was missing on multiple shifts, with no related entries in progress notes. CNAs, who were responsible for providing and documenting toileting and incontinence care in the EMR, and nursing leadership confirmed that all care should be documented and verified by supervisors, yet a CNA reported sometimes forgetting to chart when busy. This failure to follow the facility’s documentation policy resulted in an incomplete and inaccurate medical record.
A resident with dementia, depression, mixed anxiety disorder, and severely impaired cognition, who depended on staff for ADLs and communicated via written questions due to hearing impairment, reported that a male CNA had touched them inappropriately in the groin while providing a shower and that they had informed staff or the administrator shortly thereafter. The resident’s care plan was later updated to prohibit male CNAs, and documentation showed showers were provided by a male CNA on several occasions. The facility conducted an internal investigation and concluded there was no evidence to support sexual abuse, but did not notify the NJDOH as required by its abuse/neglect policy and state regulations, a failure confirmed by the DON and administrator during surveyor interviews.
A cognitively intact resident with mental health diagnoses reported that a CNA pushed them to the floor when they entered another resident’s room after hearing yelling, later seeking ED care where an abrasion of the upper extremity and a visit reason of battery were documented. An LPN documented hearing yelling, seeing the resident grabbing the CNA’s arm, and calling 911, while the CNA stated the resident aggressively grabbed her and denied assaulting the resident. Despite the resident’s repeated written complaints to the DSS and LNHA alleging assault and expressing anger when seeing the CNA, the facility did not follow its abuse policy requiring temporary suspension of employees under investigation, did not promptly obtain statements from other staff or residents on the CNA’s assignment, and allowed the CNA to continue working regular shifts, including on the unit where the resident resided.
A cognitively intact resident with psychiatric diagnoses reported that a CNA pushed them and knocked them down, after which an LPN heard yelling, entered the room, saw the resident grabbing the CNA’s arm, and then called 911 and notified the nursing supervisor. The resident requested hospital transport to document injuries and was treated in the ED for an abrasion of the upper arm and given a Tdap injection. The nursing supervisor was informed of the incident, and staff later received education on abuse and neglect policies; however, there was no evidence that the allegation of staff-to-resident physical abuse was reported to the state health department, and the ADON indicated she believed it was a resident-to-staff incident rather than a reportable staff-to-resident allegation.
Failure to Maintain ADL and Turning/Repositioning Documentation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of Activities of Daily Living (ADL) tasks, specifically getting a resident out of bed and providing turning and repositioning, for a defined period. A resident with multiple complex medical conditions, including severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 diabetes mellitus, dysphagia, a stage 4 sacral pressure ulcer, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness, was assessed as having severely impaired cognition (BIMS score of 00) and requiring staff assistance with ADLs. The resident’s care plan, initiated in September 2025 and revised in March 2026, identified moisture-associated skin damage to the sacrum related to incontinence, immobility, poor cognition, peripheral vascular disease, and diabetes, and included interventions such as turning and repositioning, offloading per policy, limiting sitting time, use of a ROHO cushion, and treatment per physician orders. Review of the resident’s Documentation Survey Reports (DSRs) from January 2026 to March 2026 showed recorded interventions and tasks including skin observation, turning and repositioning, and amount eaten, with the DSR reflecting the days these tasks were performed. However, the facility was unable to produce any DSRs or other documentation of ADL tasks for September 2025 through December 2025, despite staff interviews indicating that turning, repositioning, and getting the resident out of bed were performed and documented in the Point of Care (POC) system or skilled progress notes. The DON stated that turning and repositioning were documented by CNAs in the POC and that the resident was turned and repositioned every two hours or more frequently, but could not provide more than one month of ADL task sheets, citing a recent program change. This lack of documentation occurred despite facility policies on Turning and Repositioning and Pressure Injury Prevention and Management that require implementation and documentation of turning and repositioning for residents at risk of or with existing pressure injuries.
Insufficient Kitchen Staffing Led to Inadequate Meals
Penalty
Summary
The deficiency involves insufficient staffing in the food and nutrition services, resulting in the inability to safely and effectively carry out food service operations. During a Resident Council meeting, five of six alert and oriented residents reported that on one day the prior week there was no cook on duty and they were served cold food for all three meals. They stated that breakfast consisted of cereal and milk passed from a cart. On another day of survey observation, the Food Service Director (FSD) was observed preparing lunch and confirmed there was no cook on duty that day, so he was covering all meals himself. A Dietary Aide reported that on the day in question the scheduled cook called out sick and the FSD was also ill, leaving no cook available. The Registered Dietician (RD) was notified and instructed the Dietary Aide to use only items that did not require cooking, resulting in breakfast of cold cereal, milk, and juice; lunch of cold cut sandwiches and chips; and dinner of cold cut ham wraps, with no cooked items or vegetables provided. The RD later acknowledged that these meals did not meet daily nutritional requirements. Review of the March kitchen schedule showed only one cook scheduled for the month, with the FSD covering most cooking duties, including all breakfasts and all meals on certain days, and no backup cooks available after two cooks had quit. The facility’s own Dietary Emergency Staffing policy requires provision of safe, sanitary, and nutritionally adequate meals even in the absence of a scheduled cook, with the Administrator responsible for oversight and regulatory compliance.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health after a resident was found to have a left femur fracture. The resident had dementia with behavioral disturbances, a psychotic disorder with hallucinations, seizures, and chronic candidiasis, and was assessed on a recent MDS as moderately cognitively impaired with a BIMS score of 9/15. On 3/19/26, a hospital RN notified the facility that the resident, who had been admitted to the hospital with anemia and acute kidney injury, was also found to have left leg swelling, redness, and tenderness, and that a CT scan showed a left femur fracture. A facility document titled "Conclusion Summary of Investigation" described an acute displaced fracture of the left femur with a large adjacent hemorrhage and areas suspicious for active bleeding. During an interview, the LNHA stated that after being notified by the hospital of the fracture, the facility conducted an investigation and concluded there was no harm done in the facility, and that she was unsure where the fracture occurred, suggesting it may have happened during transfer to or at the hospital. When questioned about protocol for injuries of unknown origin, the LNHA acknowledged that the facility did not know how the injury occurred. In a separate interview, the President/CEO confirmed that an injury of unknown origin is supposed to be reported to the Department of Health and agreed that the resident’s fracture would be considered such an injury. The facility’s abuse policy, revised 1/1/2025, states that the New Jersey Department of Health and Senior Services must be called immediately to report that the facility is investigating an allegation of abuse or neglect, with written confirmation of the investigation results to follow within 72 hours. Despite this policy, the injury of unknown origin was not reported to the Department of Health.
Failure to Prevent Elopement From Secured Unit for Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was a known elopement risk. The resident had been identified as high risk for elopement since admission in 2024 and had a Wander Guard device in place. An Elopement/Wandering Risk Evaluation completed on 03/04/2026 documented a history of actual or attempted elopement, verbal expressions of wanting to go home, and exit-seeking behavior, as well as cognitive impairment with poor decision-making skills. The resident’s care plan, initiated in 2024 and revised in 2025, identified the resident as an elopement risk and wanderer with a Wander Guard on the ankle and called for monitoring of behaviors and frequent monitoring due to active exit-seeking. In early March 2026, the resident’s behavior escalated. On 03/03/2026, the resident requested transfer to a facility closer to a family member after that family member had reduced the frequency of visits. On 03/04/2026, the resident attempted to leave the floor and was hard to redirect, leading the facility to place the resident on one-to-one monitoring while awaiting a secured unit bed. The resident was then transferred to a secured third-floor unit on 03/04/2026, and the one-to-one monitoring was discontinued. Facility policy on safety and supervision stated that resident supervision is determined by assessed needs and that supervision may need to be increased with changes in mental status or behaviors. The Code Grey/Elopement policy emphasized controlling exit access on secured units, including the use of door codes to leave the unit. On the evening of 03/08/2026, the resident was observed on the secured unit by staff around 9:00 PM. One LPN reported last seeing the resident at about that time when providing a snack, after which the resident went to their room; a CNA also saw the resident in the room on the phone at 9:00 PM. Staff on the secured unit stated that residents there were allowed to go off the unit unaccompanied to a soda machine on another unit, despite the resident’s elopement risk and Wander Guard. Around 10:00 PM, staff discovered the resident was no longer in the room and could not be found on the unit. Staff on the secured unit reported not hearing any door alarm sounding prior to the activation of a Code Grey, and they did not initiate the Code Grey themselves. A nurse on another floor heard a door alarm at about 10:00 PM and activated Code Grey, after which a head count revealed the resident was missing from the building. The resident later reported having exited the secured unit through an exit door, taken the elevator to the front entrance, left the building while still wearing the Wander Guard, and used public transportation to travel to a family member’s home, where police subsequently located the resident. These events led surveyors to determine that the facility failed to maintain a safe environment on the secured unit with adequate supervision to prevent elopement, resulting in an Immediate Jeopardy finding under F689.
Removal Plan
- The DON and ADON provided immediate in-service training and began reeducation regarding safety and protocols for residents at risk for wandering and elopement.
- Upon the resident’s safe return, the resident was reassessed.
- A new Wander Guard with a secure band was placed on the resident’s ankle.
- The resident’s room was moved adjacent to the nurses’ station for monitoring.
- The resident was placed on 1:1 monitoring for all shifts.
- The DON and ADON provided facility staff education on the importance of monitoring residents’ doors on secure units to prevent residents from exiting.
- The DON and ADON in-serviced all staff on monitoring doors on secured units to prevent unauthorized exits.
- The DON and ADON in-serviced all staff that residents living on secured units need to be escorted by staff members when leaving the unit.
- Testing of all door alarms and door locks was completed and confirmed working as designed by Northeast Protection Partners.
- The Wander Guard installer completed testing of all Wander Guard alarms and magnetic locks and confirmed they are working as designed.
- A trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors and prevent unauthorized exit by all residents living on that unit.
- All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.
Failure to Document and Follow Up on Urology-Ordered Catheter-Related Procedures
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up management and care for a resident with an indwelling catheter after a urology consultation. The resident was admitted with obstructive and reflux uropathy, congenital malformation of the urinary system, and severe intellectual disabilities, and was dependent on staff for toileting with an indwelling catheter in place. A urology visit summary documented that the resident was to be scheduled for cystoscopy, laser lithotripsy of a bladder stone, and a transurethral resection of the prostate. Nursing notes indicated that the resident returned from the urology appointment with a recommendation for a future operating room schedule. However, there was no documented evidence in the electronic medical record that the facility followed up with the urologist or contacted the resident’s medical doctor regarding scheduling these procedures. Subsequently, the resident was admitted to the hospital with an obstructed Foley catheter, bilateral hydronephrosis, and acute kidney injury, and prior nursing documentation noted cloudy yellow urine, poor intake, and lethargy with an order to send the resident out for further evaluation. Interviews revealed that central supply staff, who were responsible for scheduling appointments, stated they called the urology office weekly but did not have access to the EMR and kept paper logs of attempts that were not retained. The infection preventionist, LNHA, and ADON acknowledged that there was no facility policy for scheduling out-of-facility appointments, that the process relied on central supply’s undocumented personal log, and that no consult follow-up form was completed because the urology office was expected to schedule the surgery. The facility’s charting documentation policy stated that the medical record should facilitate communication between the interdisciplinary team, but there was no documentation of follow-up attempts or escalation when the procedures were not scheduled.
Failure to Provide Meals Consistent With Diet Orders and Documented Preferences
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide meals and condiments in accordance with residents’ diet orders and documented food preferences as listed on tray tickets. During a breakfast observation, one resident reported missing items from their tray; review of the tray and ticket showed the resident did not receive a biscuit, pepper packet, or ketchup packet, despite these items being ordered. This resident had diagnoses including protein-calorie malnutrition, type 2 diabetes mellitus, and hypertension, and was on a no added salt, consistent carbohydrate diet with a care plan intervention to provide and serve diet as ordered. Another resident, observed eating breakfast in bed, reported both missing and incorrect items. The tray ticket called for a fruit cup, cranberry juice, a biscuit, salt, pepper, and ketchup, but these were not all present; instead, the resident received applesauce and apple juice, which were not on the ticket, and the ticket specifically indicated no apple products. On a subsequent breakfast observation, the same resident’s tray again lacked the ordered salt, pepper, and cranberry juice and instead contained apple juice, despite an order specifying no apple and an allergy to peach skin. This resident’s care plan included an intervention to provide food and beverage preferences. During a kitchen interview, the cook acknowledged not making enough biscuits and could not explain why condiments were missing. Additional residents experienced similar issues during lunch observations. One resident reported that a can of diet ginger ale listed on the lunch ticket was not provided, despite a care plan intervention to honor food preferences. Another resident stated they were given the wrong vegetable; chopped carrots were served instead of the chopped oriental vegetables listed on the tray ticket, even though the care plan directed staff to provide and serve diet as ordered and honor food preferences. A further resident reported receiving gravy on both roast pork and mashed potatoes when the tray ticket documented a preference for no gravy, despite a care plan intervention to honor food preferences. The Food Service Director and DON both stated that tray tickets and meal trays should match and that meals should be consistent with residents’ preferences as indicated on the tray cards, but were unable to explain the missing condiments.
Failure to Maintain Complete and Accurate Toileting and Continence Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with diagnoses including a cervical vertebra fracture, heart failure, and type II diabetes. The resident’s comprehensive MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and documented that the resident required substantial assistance with toileting hygiene and toilet transfer. The care plan identified the resident as being at risk for skin breakdown, having incontinent episodes, and having a self-care performance deficit, with interventions such as routine incontinence checks, offering toileting every 2–3 hours, keeping the skin clean and dry, and providing one-person assistance for toileting and all transfers. The Documentation Survey Report for January specified that bladder continence, bowel continence, bowel movements, and toilet use were to be documented each shift. Record review showed missing documentation for multiple dates and shifts for bladder continence, bowel continence, bowel movements, and toilet use, with no corresponding entries in the progress notes to account for this care. Interviews with the LPN Unit Manager, a CNA, the DON, and the LNHA confirmed that CNAs were primarily responsible for providing toileting and incontinence care and were expected to document all care in the EMR, and that supervisors were responsible for verifying that documentation was completed. The CNA interviewed acknowledged sometimes forgetting to document care when busy. The facility’s charting and documentation policy required that all services provided to residents be documented completely and accurately, including treatments or services performed, which was not followed in this case, resulting in incomplete medical records for the resident.
Failure to Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the New Jersey Department of Health (NJDOH) as required by regulation and its own abuse/neglect policy. A resident with diagnoses including dementia, depression, and mixed anxiety disorder, and with severely impaired cognition per the most recent MDS, was dependent on staff for ADLs such as toileting hygiene, showering, and lower body dressing. During a surveyor interview conducted using written questions due to the resident’s hearing impairment, the resident stated they preferred only female CNAs to provide care and reported that a few months earlier a male CNA, whose name sounded like a specific individual, had touched them inappropriately in the groin area while giving a shower. The resident indicated they had reported this incident to either someone who changed them or to the administrator on or shortly after the day it occurred. The resident’s care plan, revised at a later date, included an intervention specifying no male CNAs, and point-of-care documentation showed the resident received showers on multiple dates, which the DON identified as having been provided by a specific male CNA. The facility initiated an internal investigation, including interviews, staff statements, and record reviews, and concluded there was no evidence to support the allegation of sexual abuse. However, the investigation file contained no documentation that the NJDOH was notified of the allegation. In interviews, the DON described the facility’s process for handling abuse allegations, including reporting to NJDOH within specified time frames if an event is deemed reportable, and the administrator acknowledged that the allegation should have been reported to NJDOH but was not. The facility’s written policy required immediate notification (as soon as possible but not to exceed 2 hours) to the Department of Health and Senior Services and the Office of the Ombudsman for residents 60 or over, followed by a written report within 5 days, which was not followed in this case.
Failure to Remove Alleged Perpetrator and Fully Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from alleged abuse by a CNA and failure to implement its abuse policy after learning of the allegation. A cognitively intact resident with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder reported that a CNA pushed them, causing them to fall, when they entered another resident’s room after hearing yelling and crying. An ED after-visit summary documented that the resident was seen for battery and diagnosed with an abrasion of the left upper extremity. The facility’s own abuse/neglect policy stated that employees under investigation would be temporarily suspended until the Administrator reviewed the results of the investigation, but this was not followed for the CNA involved. On the date of the incident, an LPN documented that they heard yelling from another resident’s room and, upon entering, observed the resident yelling and grabbing the CNA’s left upper arm. The LPN reported asking the resident to leave the CNA alone, then leaving the room to notify the Nursing Supervisor and call 911. The CNA’s written statement asserted that the resident grabbed her in an aggressive manner to cause physical harm and that she did not assault the resident. The facility administration later reviewed video footage and statements from the CNA and the LPN and concluded there was no merit to the resident’s accusatory statement, citing the resident’s mental health history, and asked the CNA to return to her scheduled shift. On multiple occasions following the incident, the resident sent emails to the Director of Social Services and the LNHA stating that the CNA had assaulted them and expressing distress that the incident was not addressed. Despite these communications, the facility did not obtain statements from other staff members beyond the alleged perpetrator, the LPN, and the Nursing Supervisor, and did not interview or obtain statements from other residents typically on the CNA’s assignment until after the surveyor requested investigation documents. Payroll and assignment records showed that the CNA continued to work regular shifts, including on the behavior unit where the resident lived, both immediately after the incident and after the resident’s written allegation of assault. Facility staff, including the DSS, LNHA, and ADON, acknowledged the resident’s ongoing anger when seeing the CNA on the unit and referenced the resident’s history of aggressive and explosive behavior, but the facility did not remove the CNA from resident care or from the resident’s unit in accordance with its abuse policy when the allegation was reported.
Removal Plan
- Resident #1 had a follow up consultation with the Statewide Clinical Outreach Program for the Elderly (S-COPE)
- ADON conducted abuse policy re-education for nursing staff post incident
- The Administrator and the ADON were re-educated on the Abuse Policy and Procedure and Federal deficiency F600 (free from abuse and neglect) by the President of Clinical Services
- The ADON and the Regional Nurse Consultant provided 1:1 re-education on the Abuse Policy to the Registered Nurse Supervisor involved in the incident
- ADON began facility-wide education for all staff on the Abuse Policy to protect all residents from abuse
- Unit managers and Nursing Supervisors were re-educated by ADON on the Abuse Policy and the requirement to report
- The Social Worker conducted additional interviews on the two units assigned to the CNA
Failure to Report Alleged Staff-to-Resident Physical Abuse to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health an allegation of physical abuse involving a resident and a CNA. The cognitively intact resident, with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder, reported that a CNA pushed them and knocked them down. A behavior note documented that an LPN heard yelling and shouting in another resident’s room where the CNA was providing care, and when the LPN entered, the resident was observed grabbing the CNA’s arm. The LPN then exited the room to call 911 and notify the nursing supervisor. A facility event summary indicated that the resident called 911 and requested transport to the hospital to document injuries allegedly sustained from being physically assaulted by the CNA. Emergency department records showed the resident was treated for an abrasion of the left upper arm and received a Tdap injection. A nursing supervisor’s witness statement documented that she was made aware of an incident between the resident and the CNA. Facility documents showed that staff were in-serviced on abuse and neglect policies and procedures following the incident, but there was no evidence that the allegation of abuse was reported to the New Jersey Department of Health. During an interview, the ADON stated that the facility would notify the Department of Health for alleged abuse, major injury, and staff-to-resident abuse, but indicated she believed this incident was considered a resident-to-staff incident rather than a staff-to-resident allegation, and thus it was not reported as required.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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